Fear Is Where You Start From

Recently I was having dinner with some colleagues, who were discussing the state of mental health and managed care.  When these conversations start I sometimes begin to sit back, because I anticipate the worst.  I expect that there will be some insurance bashing, and then discussion of how their salaries have shrunk, and how unfair the current system is, maybe a smattering of how better things used to be for our profession and concluding with uncertainty about how much longer they can stay in business.  I expected this conversation to go the same way, and was preparing to decide whether to try to advocate for another, more empowering perspective.

I was pleasantly surprised.

The conversation did indeed start with the understandable concerns of therapists trying to grapple with the seismic shifts in our careers and businesses.  But then one of them began to talk about how he was planning to change the way he did business.  Others expressed curiosity about the things he was trying, and I finally offered a couple of ideas.  When they found out that I provide consultation on building & maintaining your therapy practice, they were 100% enthusiastic and eager to hear some positive perspectives.  They were able to hear my opinions of some tough truths, that we had bought into the managed care model because we were reluctant to market our businesses and have difficult conversations with patients about payment.  No one was defensive at all, one even invited me to come talk with a local group of colleagues.  At one point they made a joke about my “secrets” for success, and I told them I am not one of those people who holds back secrets to hook people into working with me, and that they could find a lot of free info on my site.

“I was kidding about having a secret,” one told me.  “You don’t have a secret, what you have is a strategy.”

The Buddhist teacher Pema Chodron writes in her book of the same title, about going to “The Places That Scare You.” The goal of the Tibetan Buddhist practice of tonglen, or taking and sending, is to reverse the normal cycle of human existence.  Rather than seeking out things we desire and avoiding suffering, the meditation practice of tonglen asks us to imagine inhaling and taking in the suffering for all sentient beings and exhaling happiness to send it to all sentient beings.  Whether you believe in the mystical qualities of this, the principle is a useful one in that it teaches us to break the instinctual habit of trying to holding on to the things we like and get rid of the things we don’t.  A version of this is going to the places that scare you, rather than running away from them.

The clinicians I have mentioned above are well on their way to maintaining and vastly improving their private practices, and its got nothing to do with me.  They have realized that fear is real, and that it often is mistaken for the end of the line.  They get that it is the opposite.

Fear is the place you start from.

People who deny that things are changing are in my opinion in for a rude awakening.  They deny the way our profession is being challenged, the importance of emerging new technologies, and the evolving practice of psychotherapy.  They deny the things that would evoke fear in them.  This is not unique to therapists of course.  Ironically, we often work trying to help patients see the devastating impact on their lives of repressing anxiety-provoking truths.  Then we turn around and do the same things to ourselves, hoping that this change in  economics or technology is “more of the same.”  Folks in this group are in pre-contemplation of fear, they haven’t even gotten that far.

Then there are clinicians who have gotten that things are really changing, and they are terrified!  They are paralyzed and miserable, commiserating with others and talking about the way things were in the past and how much better they were then.  They see the point of fear and they think of it as the period on a life’s sentence of struggling.  This is the end of our careers, we can’t learn to use technology, therapy is a dying art form.  They give up, and go out of business in a lingering dwindling sort of way.

Fear is not the endpoint.  Fear is where you begin. Fear is where you get going and hire a coach, research and write up a business plan, take a workshop on business development, marketing or integrating new technologies.  Fear is the start of renovating your practice.  Yes there is a lot of suffering in the world, let’s get going and reduce it.

Epic Therapists know all about fear. They aren’t fearless, there’s a lot to be worried about.  Many businesses fail, money needs to be spent to make money later, there are long hours ahead and no structure but the one they give themselves.  There is a lot they don’t know, a lot they’ve never learned to do to run a business, known expenses and surprises.  But Epic is running toward that dragon, knowing this could be an epic failure, being afraid… and then doing it anyway.

Epic Therapists have learned the concept of “nevertheless.”  I am scared that my business will fail, nevertheless I am starting it.  I am afraid that I’ll rent an office full-time and not be able to find patients, nevertheless I am going to rent one.  I am afraid I’ll sound inauthentic or greedy if I talk about my business to a colleague, nevertheless I am going to talk about my business.  I am afraid no one will want to pay my fee, nevertheless I am going to set a firm “bottom line” fee for myself.  I am afraid that I won’t be able to keep up with the changes in healthcare or technology, nevertheless I am going to make a strategy.

My last post about having a secret headquarters was fun to make, and it was also serious.  We need to have a time and a place for strategizing.  We can absolutely have fun doing it, but this is serious business.  There really are things to fear in healthcare, building a private practice and starting a business.  We need to think carefully and plan, and then we need to begin.

The Truth? You Can Handle The Truth.

photo courtesy of informedvote.ca

One of my favorite quotes from Pema Chodron is when she explains the first Noble Truth of Buddhism:  “Existence is Suffering.”  In her book When Things Fall Apart she writes:

The first noble truth of the Buddha is that when we feel
suffering, it doesn’t mean that something is wrong. What
a relief. Finally someone told the truth. Suffering is part of
life, and we don’t have to feel it’s happening because we
personally made the wrong move.

Patients often come to me to hoping therapy will make them feel good.  I tell them that that is not what psychotherapy is for.  Psychotherapy is not aimed at making you feel good:  Psychotherapy helps you learn how to not feel good, at least the way I practice it.  Because the truth is out, there is suffering in the world, and in our lives.  Can we learn how to not feel good?  How to sit with what feelings arise without eating, starving, cutting, drinking, smoking, sexing our way out of it?  Although I didn’t coin the phrase “Don’t just do something, sit there,” my patients often hear it for the first time in our work together.

When I consult with therapists on how to build their practice, or how to use technology, you’d be surprised how much shame, anger and sadness can come up for them.  A lot of times they have been avoiding looking at how they do the business part of their work, as if it were completely divorced from their fears of failure, grandiose defenses, and ethical quandries.  It takes courage to get to the tender spot that is hurting their business.  We have to weave our way past the following bugbears:

“I don’t do this for the money, I do it for the patients.”

“I don’t care if what I tell the insurance company I’m charging is what I’m actually charging, insurance companies are evil.”

“Whatever I have to do to play the game is fine, as long as I can do good work with my patients.”

“I don’t want to know how this billing, marketing, business stuff works, my practice is doing just fine.”

“I don’t know anything about Skype, and I don’t really care.”

One of the great things about working with therapists, though, is that sooner rather than later they hear the defensiveness in their words, and we settle down to not feel good together so we can clear away the shame cluttering their practice.  Generally what I find is that their shame comes down to this, see if this internal monologue sounds familiar:

“I have suffered long and hard to get where I am today.  I have worked long hours for free, spent money I didn’t have, to get an education that is often undervalued in the world.  Even before that, I was always helping people in my life, even when they were supposed to be taking care of me.  I waited for someone to notice that I was trying so hard, and finally I gave up.  I’m going to have to take care of myself, no one else will.  But even though I’ve built my life and work up around that structure, part of me waits with fear for someone to take my work and livelihood away from me.  Sooner or later they are going to figure out that I have been faking this adult thing, this independent therapist thing, and then it will be all over, and I won’t have even that.”

If any of this sounds familiar to you, if it is what lies underneath the fears and the avoidance that are gumming up your practice, please read on.

Things were difficult for you, and you didn’t do anything personally wrong to bring this upon yourself.  Things will be difficult again, and that won’t be because somebody discovers and punishes you.  Suffering is part of life, and we need to pay attention to it, but not personalize it.  The clearer you get with this the more clearly you’ll be able to look at your work and business.  And the more you do this, the more you’ll face your fears and start to practice in an integrated way, and make money.

On the other hand, if you insist on living your life and practicing your work in accordance with the narrative of fear and entitlement above, all bets are off.  Paradoxical perhaps, but maybe you have already noticed how we can manifest irrational fears into real life.  Because these fears are the ones that have you stuttering on the phone to UBH during peer reviews, or getting nervous whenever a patient or their insurance company has a billing question.  These feelings of anger and entitlement are what make you envious of your colleagues when they try something new in their practice, or promote a book, or launch an online practice.  Leave these fears unchecked and your practice will get more rigid, the walls of your office more close, and even if you never get caught for some of the business practices you do you’ll tire yourself out justifying yourself.

I love it when colleagues come to work with me and trust me to tell them the way I see it.  I love it when we get honest and the fear starts to go away.  I love the relief and the organization that comes in its place.  I see priorities shift, new models of working open up, and people rediscover why they like being a therapist.  And I see them make more money with less guilt.

You may not agree with everything I write here, and you may not see psychotherapy or business practices the same way I do.  No one, least of all me, thinks you should.  But my blog is much like working with me in person, I promise I’ll call it as I see it.  I think anything less is  a waste of your time and money and disrespectful to you.  And I won’t collude with you in your disrespecting yourself.